Hysterectomy Complications

Author: Kristine Jeffers, MD (EM Physician, San Antonio Uniformed Services Health Education Consortium) // Reviewed by: Jessica Pelletier, DO (EM Education Fellow, Washington University in St. Louis); Marina Boushra (EM-CCM Physician, Cleveland Clinic Foundation); Brit Long, MD (@long_brit)

Case

A 45-year-old female presents to the ED with a chief complaint of vaginal and abdominal pain. She is status post (s/p) hysterectomy 2 weeks ago. She had been feeling well until yesterday when she had a follow-up with her surgeon, at which time she reported that they performed an internal exam and inserted a ‘medication disk’ into her vagina. Since then, she has had worsening severe pain in her abdomen and vagina.

The patient is noted to be mildly tachycardic as well as febrile. She has a diffusely tender abdomen with guarding. A speculum pelvic exam to locate the ‘medication disk’ is notable for no foreign body but bowel is noted at the top vaginal vault.

Introduction

Hysterectomies are one of the most common gynecological surgeries conducted in the United States. Over 600,000 procedures are performed annually, and an estimated 1/3 of women will have undergone a hysterectomy by the time they reach the age of 60 (1,2). Surgical approaches to the procedure include open abdominal, transvaginal, and laparoscopic. The route chosen depends on a patient’s age, uterine volume, body mass index (BMI), prior surgeries, and parity (1). Total abdominal hysterectomy (TAH) is associated with a slightly higher complication rate than laparoscopic hysterectomy (LH) or vaginal hysterectomy (VH) (3,4). Operative complications requiring surgical intervention or hospitalization occur in about 3-6% of all hysterectomies (5).

During a hysterectomy, the uterus and cervix are removed (partial hysterectomy) or the uterus, cervix, and ovaries are removed (complete hysterectomy). The vagina is left as a blind pouch and the vaginal cuff (the area at the top of the vagina) is closed with sutures. There should be no erythema, purulent drainage, bleeding, or opening in that incision on pelvic exam. If there are abnormal findings on clinical exam further examination may be warranted.

Common Complications

Complications can be categorized by type of injury as well as timing relative to the procedure. Temporal categorization includes perioperative complications, which occur (<7 days from surgery, or delayed complications, which can occur 1-6 weeks after surgery. Perioperative complications include fever, ileus, pulmonary embolism, C. difficile infection, and post-operative hemorrhage. Delayed complications include wound infection, seroma, hematoma, bowel injury, and vaginal cuff dehiscence (1). Complications will be discussed by category here.

Infectious Complications – The risk of postoperative infection can be as high as 20% without proper antibiotic prophylaxis and is reduced to about 7% with proper prophylaxis (6). Fever occurs in the immediate postoperative period in up to 50% of patients (6). The degree of workup pursued in response to a fever should be dictated based on the patient’s clinical symptoms. Routine screening of complete blood count (CBC), chest x-ray, blood cultures, or urine cultures have been found to rarely yield positive results in the absence of clinical symptoms (6).  The following are common infectious etiologies of fever s/p hysterectomy:

1. Vaginal Cuff Cellulitis: This condition occurs in about 2% of patients and is one of the most common infectious complications. It typically presents in the first several days postoperatively (2,6). The presence of bacterial vaginosis or trichomonas vaginitis preoperatively is associated with an increased risk of cuff cellulitis in the postoperative period. Patients may present with fever, back pain, lower abdominal pain, pelvic pain, or vaginal discharge (2). On pelvic exam the vaginal cuff may appear indurated or erythematous, may exhibit purulent discharge, and will be tender to palpation (2,6). Treatment should involve a second- or third-generation cephalosporin (with the addition of metronidazole for associated trichomoniasis or doxycycline for chlamydia) and should be continued for 48 hours after fever cessation (2).
2. Abscess and Infected Hematoma: This condition is typically delayed, occurring most commonly 10-14 days post-operatively. Patients may present with fever, pelvic pain, or rectal pressure. On pelvic exam, there may have a fluctuant mass at the vaginal cuff or purulent discharge from the cuff (6). Labs may demonstrate anemia in the setting of an infected hematoma. An elevated white blood cell count may also be seen (2). Patients should be started on empiric broad-spectrum intravenous (IV) antibiotics until the patient is afebrile for 48 hours (6). Antibiotics should cover gram-negative bacilli, enterococci, streptococci, and anaerobes and the infections are often polymicrobial (10). If the fluid collection is greater than 5 cm in diameter they should be referred for surgical drainage (2).
3. Wound Infection: Infections of the abdominal incisions typically are seen about 7 days after surgery (6). As many as 20% of women may experience a skin or soft tissue infection but these are less common in LH than in TAH (2,6). Patients may present with fever, pain, purulent drainage, foul odor, or wound dehiscence (2,6). Wound infections should be treated with antibiotics targeting Staphylococcal and Streptococcal infections and may need to be incised and debrided to resolve the infection (2,6). A vacuum-assisted wound dressing may also be applied to aid in healing (2).
4. Urinary Tract Infection (UTI): When a patient presents with a postoperative fever on days 3-5 and dysuria, a urinalysis should be obtained, especially if the patient was catheterized during the procedure or if they have localizing signs of urinary tract infection (6). UTI accounts for 40% of nosocomial infections and Coli is still the most common organism identified (2). Symptoms may include fever, urinary frequency, urgency, hematuria, or dysuria. Diagnosis is confirmed by urinalysis and treated with antibiotics such as nitrofurantoin or trimethoprim-sulfamethoxazole.
5. Pneumonia: Pneumonia occurs in the first several days post-operatively and is most common in patients with underlying lung disease. Patients may present with shortness of breath, fevers, chills, cough, chest pain, and increased sputum production. Physical exam may demonstrate rales, crackles, hypoxia, tachypnea, tachycardia, or fever. Patients may be treated with a third-generation cephalosporin, fluoroquinolone, doxycycline, or amoxicillin-clavulanate (2). With changes in the IDSA guidelines and the removal of HCAP, most people should be treated with antibiotics that will treat CAP organisms as most of these patients still have a very low incidence of multidrug-resistant organisms. However, if a patient is septic, has severe illness, history of multidrug-resistant organisms or other concerning features a broad-spectrum antibiotic to cover HAP organisms should be initiated.

Non-Infectious Pathological Complications

1. Venous thromboembolism (VTE): When a patient presents with a fever on post-operative days 4-6 the provider should think about VTE as the cause (6). Half of all embolisms occur within the first 24 hours and 75% will present by postoperative day 3. VTE is one of the most common complications of gynecological surgery (2). Diagnosis can be confirmed with ultrasound (for deep vein thrombosis) or CT angiography (CTA) chest (for pulmonary embolism) and patients treated with anticoagulants.
2. Blood Loss: This can be a relatively common complication of hysterectomy. Twice as many women undergoing LH require transfusion vs VH (6). Care must be taken during surgery to ensure that good hemostasis is achieved. If there is concern for significant bleeding based on clinical findings of conjunctival pallor, tachycardia, hypotension, or heavy bleeding a CBC, type and screen, and coagulation studies should be obtained, keeping in mind that there may be a delayed drop in hemoglobin during acute blood loss. Bleeding may or may not be seen on physical exam. On pelvic exam, bleeding may be localized to the vaginal cuff and easily visualized. If bleeding is not seen externally a patient may still be bleeding internally (especially if they have increased abdominal pain or distention) and a FAST exam or pelvic ultrasound can locate pelvic hematomas or other free fluid in the abdomen.

Anatomical Injuries

1. Gastrointestinal injuries (GI): Injuries to the GI tract occur in about 1% of hysterectomies (1). There are three types of injuries to the bowel: Thermal injury, direct mechanical injury, and indirect injury due to interruption of blood supply (1). Thermal injuries can occur when cautery is used where there is unclear visualization like in the deep pelvis, at the cuff, or in the cul-de-sac. These injuries may go unnoticed at the time of surgery and if left unrepaired they often have a delayed onset of infection and symptoms (1). Direct injury occurs from instruments during surgery and occurs most often during adhesion removal. Vascular injuries can occur due to disruption of blood supply to the mesentery and very rarely occur during a routine hysterectomy (1). These are often recognized at the time of surgery but if small lesions go unnoticed patients may develop signs of postoperative peritonitis and infection after surgery. Patients may present with fever, elevated WBC, nausea, vomiting, abdominal distention, or peritonitis and this may not be seen for days to weeks postoperatively (2). Thermal and direct injuries can be diagnosed with CT with oral contrast. These injuries tend to present with peritonitis as bowel contents are leaked into the abdomen. Concern for vascular injury should be evaluated with CTA and tend to present with severe pain out of proportion to physical exam. GI tract injuries require operative repair for definitive management and may require IV antibiotics (2).
2. Genitourinary (GU) injuries: Injuries to the genitourinary tract occur in about 2% of major gynecological surgeries with 75% of these occurring during a hysterectomy (2). A GU injury is twice as likely to occur if the surgery is performed laparoscopically (2% vs. 1 %) (1). The urinary bladder may become injured during dissection of surgical planes, but this is often noted at the time of surgery. Serosal injuries may go unnoticed as they are not full-thickness injuries. These can lead to delayed cystotomy and vesicovaginal fistula formation. Patients are at an increased risk of bladder injury if they have had a cesarean delivery, endometriosis, pelvic adhesions, or cancer (1). Patients may present with fever, hematuria, abdominal pain, ascites, or peritonitis. Labs may demonstrate hyponatremia, hyperkalemia, and elevated creatinine. If an injury to the GU system is suspected a cystogram or CT with IV contrast may help identify the injury (2).
3. Neuropathy: Occurs rarely (about 2% of gynecological cases) (6). The femoral nerve is the most common nerve affected by pelvic surgeries and injury occurs when pelvic retractors are placed where the nerve runs along the anterior aspect of the psoas muscle or when a patient is hyperflexed at the hip in the lithotomy position the nerve may become pinched in the inguinal canal (2). Patients may experience sensory changes over the anterior thigh down to the foot or weakness in the quadriceps muscle. The other nerves that may be affected during hysterectomy are the iliohypogastric and ilioinguinal nerves which may be injured during a wide abdominal incision. Spontaneous resolution of nerve injuries may occur over days to months based on the severity of the original injury (2).
4. Vaginal cuff dehiscence: This is a relatively rare complication occurring in about 0.3% of cases and occurs on average 11 weeks postoperatively, but may even be seen several years after surgery (1,2,6,7). This is also more commonly seen after LH (1.5%) compared to VH or TAH (0.1%) (1,2,7,8). Vaginal closure of the cuff also has the lowest rate of dehiscence (1). It may present with vaginal bleeding (the most common presenting symptom) (3), or watery vaginal discharge (2,6). A patient may experience pelvic pressure or a bulge in the vagina if bowel evisceration occurs (1,7). This may also predispose a patient to sepsis, peritonitis, or bowel infarction, which need to be recognized quickly. The largest risk factor for dehiscence is direct trauma from sexual intercourse, usually during the first postoperative coitus (1,6). Diagnosis is made via a speculum examination (Figure 1). When opening the speculum and looking at the top of vaginal pouch you should not see any defects in the incision. If the top of the pouch is opening at any point this is concerning for dehiscence. Once diagnosed the patient should be treated with broad-spectrum antibiotics and referred to OB/GYN for operative repair (6).
   Figure 1: Dehiscence of the vaginal cuff with visible loops of bowel at the incision site.

Conclusion

Hysterectomy is a common gynecological surgery and the emergency clinician must be prepared to diagnose and manage associated postoperative complications. Complications can be infectious, non-infectious, and anatomical/surgical, and labs/imaging should be obtained based on the symptoms elicited in the patient history. Many complaints will require imaging, and the clinician should maintain a low threshold to start broad-spectrum IV antibiotics if there is high suspicion for intra-abdominal infection. Consideration should be made for contacting the operating surgeon early as they may need to re-admit or take the patient to the OR for definitive care.

Pearls and Pitfalls

• Complications that will present to the ED in the first one to two weeks are typically due to infection.
• Even though if surgery was weeks, months, or years ago, complications related to the surgery (cuff dehiscence, injuries to bowel or bladder) can still present.
• A thorough history and physical examination will guide imaging and laboratory evaluation.
• Early involvement of the patient’s surgeon is paramount.

References

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